34101 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION 01 00 10 2/1/1999 $118.00 34101 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION 01 00 20 2/1/1999 $590.50 34101 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION 34101 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION 01 00 40 2/1/1999 $283.50 34490 THROMBECTOMY, DIRECT OR WITH CATHETER; AXILLARY AND SUBCLAVIAN VEIN, BY ARM INCISION 01 00 10 2/1/1999 $97.00 34490 THROMBECTOMY, DIRECT OR WITH CATHETER; AXILLARY AND SUBCLAVIAN VEIN, BY ARM INCISION 01 00 20 2/1/1999 $485.50 34490 THROMBECTOMY, DIRECT OR WITH CATHETER; AXILLARY AND SUBCLAVIAN VEIN, BY ARM INCISION 34490 THROMBECTOMY, DIRECT OR WITH CATHETER; AXILLARY AND SUBCLAVIAN VEIN, BY ARM INCISION 01 00 40 2/1/1999 $177.50 35875 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; 01 00 10 2/1/1999 $126.00 35875 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; 01 00 20 2/1/1999 $630.00 35875 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; Page 1 of 34
35875 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; 01 00 40 2/1/1999 $295.00 35876 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; WITH REVISION OF ARTERIAL OR VENOUS GRAFT 01 00 10 2/1/1999 $161.98 35876 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; WITH REVISION OF ARTERIAL OR VENOUS GRAFT 01 00 20 2/1/1999 $809.92 35876 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; WITH REVISION OF ARTERIAL OR VENOUS GRAFT 35876 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; WITH REVISION OF ARTERIAL OR VENOUS GRAFT 01 00 40 2/1/1999 $404.00 36145 INTRODUCTION OF NEEDLE OR INTRACATHETER; ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (CANNULA, FISTULA, OR GRAFT) 01 00 25 2/1/1999 $440.50 36145 INTRODUCTION OF NEEDLE OR INTRACATHETER; ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (CANNULA, FISTULA, OR GRAFT) 11 00 27 1/1/1999 $1,293.00 36145 INTRODUCTION OF NEEDLE OR INTRACATHETER; ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (CANNULA, FISTULA, OR GRAFT) 01 00 40 2/1/1999 $264.00 36488 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN)(E.G., FOR HEMODIALYSIS); PERCUTANEOUS, AGE 2 YEARS OR UNDER 01 00 25 2/1/1999 $88.00 36488 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN)(E.G., FOR HEMODIALYSIS); PERCUTANEOUS, AGE 2 YEARS OR UNDER 01 00 40 2/1/1999 $130.00 36489 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (E.G., FOR HEMODIALYSIS); PERCUTANEOUS, OVER AGE 2 01 00 25 2/1/1999 $88.00 Page 2 of 34
36489 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (E.G., FOR HEMODIALYSIS); PERCUTANEOUS, OVER AGE 2 36489 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (E.G., FOR HEMODIALYSIS); PERCUTANEOUS, OVER AGE 2 01 00 40 2/1/1999 $130.00 36490 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (E.G., FOR HEMODIALYSIS); CUTDOWN, AGE 2 YEARS OR UNDER 01 00 25 2/1/1999 $108.00 36490 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (E.G., FOR HEMODIALYSIS); CUTDOWN, AGE 2 YEARS OR UNDER 36490 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (E.G., FOR HEMODIALYSIS); CUTDOWN, AGE 2 YEARS OR UNDER 01 00 40 2/1/1999 $235.00 36491 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN)(E.G., FOR HEMODIALYSIS); CUTDOWN, OVER AGE 2 01 00 25 2/1/1999 $218.50 36491 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN)(E.G., FOR HEMODIALYSIS); CUTDOWN, OVER AGE 2 11 00 27 1/1/1999 $1,160.00 36491 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN)(E.G., FOR HEMODIALYSIS); CUTDOWN, OVER AGE 2 01 00 40 2/1/1999 $174.50 36493 REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER UNDER FLUOROSCOPIC GUIDANCE 01 00 25 2/1/1999 $44.00 36533 INSERTION OF IMPLANTABLE VENOUS ACCESS PORT, WITH/WITHOUT SUBCUTANEOUS RESERVOIR 01 00 20 2/1/1999 $308.00 Page 3 of 34
36533 INSERTION OF IMPLANTABLE VENOUS ACCESS PORT, WITH/WITHOUT SUBCUTANEOUS RESERVOIR 36533 INSERTION OF IMPLANTABLE VENOUS ACCESS PORT, WITH/WITHOUT SUBCUTANEOUS RESERVOIR 01 00 40 2/1/1999 $157.50 36534 REVISION OF IMPLANTABLE VENOUS ACCESS PORT AND/OR SUBCUTANEOUS RESERVOIR 01 00 20 2/1/1999 $250.00 36534 REVISION OF IMPLANTABLE VENOUS ACCESS PORT AND/OR SUBCUTANEOUS RESERVOIR 36534 REVISION OF IMPLANTABLE VENOUS ACCESS PORT AND/OR SUBCUTANEOUS RESERVOIR 01 00 40 2/1/1999 $118.00 36535 REMOVAL OF IMPLANTABLE VENOUS ACCESS PORT AND/OR SUBCUTANEOUS RESERVOIR 01 00 20 2/1/1999 $125.00 36535 REMOVAL OF IMPLANTABLE VENOUS ACCESS PORT AND/OR SUBCUTANEOUS RESERVOIR 36535 REMOVAL OF IMPLANTABLE VENOUS ACCESS PORT AND/OR SUBCUTANEOUS RESERVOIR 01 00 40 2/1/1999 $75.00 36620 ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS 01 00 25 2/1/1999 $58.00 36620 ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS 36620 ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS 01 00 40 2/1/1999 $48.00 Page 4 of 34
36800 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); VEIN TO VEIN 01 00 25 2/1/1999 $218.50 36800 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); VEIN TO VEIN 36800 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); VEIN TO VEIN 01 00 40 2/1/1999 $118.00 36810 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE; (SEPARATE PROCEDURE); ARTERIOVENOUS EXTERNAL (SCRIBNER TYPE) 01 00 20 2/1/1999 $336.00 36810 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE; (SEPARATE PROCEDURE); ARTERIOVENOUS EXTERNAL (SCRIBNER TYPE) 36810 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE; (SEPARATE PROCEDURE); ARTERIOVENOUS EXTERNAL (SCRIBNER TYPE) 01 00 40 2/1/1999 $165.50 36815 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); VEIN TO VEIN ARTERIOVENOUS, EXTERNAL REVISION, OR CLOSURE 01 00 20 2/1/1999 $189.00 36815 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); VEIN TO VEIN ARTERIOVENOUS, EXTERNAL REVISION, OR CLOSURE 36815 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); VEIN TO VEIN ARTERIOVENOUS, EXTERNAL REVISION, OR CLOSURE 01 00 40 2/1/1999 $94.50 36821 ARTERIOVENOUS ANASTOMOSIS, DIRECT, ANY SITE (E.G..CIMINO TYPE) (SEPARATE PROCEDURE) 01 00 20 2/1/1999 $800.00 Page 5 of 34
36821 ARTERIOVENOUS ANASTOMOSIS, DIRECT, ANY SITE (E.G..CIMINO TYPE) (SEPARATE PROCEDURE) 36821 ARTERIOVENOUS ANASTOMOSIS, DIRECT, ANY SITE (E.G..CIMINO TYPE) (SEPARATE PROCEDURE) 01 00 40 2/1/1999 $231.00 36825 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT 01 00 20 2/1/1999 $960.00 36825 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT 36825 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT 01 00 40 2/1/1999 $231.00 36830 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT 01 00 10 2/1/1999 $192.00 36830 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT 01 00 20 2/1/1999 $960.00 36830 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT 36830 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT 01 00 40 2/1/1999 $231.00 36832 REVISION OF AN ARTERIOVENOUS FISTULA, WITH OR WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS GRAFT (SEPARATE PROCEDURE) 01 00 10 2/1/1999 $192.00 Page 6 of 34
36832 REVISION OF AN ARTERIOVENOUS FISTULA, WITH OR WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS GRAFT (SEPARATE PROCEDURE) 01 00 20 2/1/1999 $960.00 36832 REVISION OF AN ARTERIOVENOUS FISTULA, WITH OR WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS GRAFT (SEPARATE PROCEDURE) 36832 REVISION OF AN ARTERIOVENOUS FISTULA, WITH OR WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS GRAFT (SEPARATE PROCEDURE) 01 00 40 2/1/1999 $231.00 36835 INSERTION OF THOMAS SHUNT (SEPARATE PROCEDURE) 01 00 10 2/1/1999 $143.00 36835 INSERTION OF THOMAS SHUNT (SEPARATE PROCEDURE) 01 00 20 2/1/1999 $715.00 36835 INSERTION OF THOMAS SHUNT (SEPARATE PROCEDURE) 01 00 40 2/1/1999 $231.00 36860 CANNULA DECLOTTING (SEPARATE PROCEDURE); WITHOUT BALLOON CATHETER 01 00 20 2/1/1999 $384.00 36860 CANNULA DECLOTTING (SEPARATE PROCEDURE); WITHOUT BALLOON CATHETER 11 00 27 1/1/1999 $943.00 36860 CANNULA DECLOTTING (SEPARATE PROCEDURE); WITHOUT BALLOON CATHETER 01 00 40 2/1/1999 $216.50 36861 CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER 01 00 20 2/1/1999 $384.00 36861 CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER 11 00 27 1/1/1999 $943.00 Page 7 of 34
36861 CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH BALLOON CATHETER 01 00 40 2/1/1999 $216.50 49420 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE OR DIALYSIS, TEMPORARY 01 00 20 2/1/1999 $150.50 49420 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE OR DIALYSIS, TEMPORARY 49421 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE OR DIALYSIS, PERMANENT 01 00 20 2/1/1999 $200.00 49421 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE OR DIALYSIS, PERMANENT 49421 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE OR DIALYSIS, PERMANENT 01 00 40 2/1/1999 $160.00 49422 REMOVAL OF PERMANENT INTRAPERITONEAL CANNULA OR CATHETER 01 00 20 2/1/1999 $386.30 49422 REMOVAL OF PERMANENT INTRAPERITONEAL CANNULA OR CATHETER 50200 RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE 01 00 25 2/1/1999 $138.00 50200 RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE 50200 RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE 01 00 40 2/1/1999 $39.50 50205 RENAL BIOPSY; PERCUTANEOUS, BY SURGICAL EXPOSURE OF KIDNEY 01 00 10 2/1/1999 $62.50 Page 8 of 34
50205 RENAL BIOPSY; PERCUTANEOUS, BY SURGICAL EXPOSURE OF KIDNEY 01 00 25 2/1/1999 $312.00 50205 RENAL BIOPSY; PERCUTANEOUS, BY SURGICAL EXPOSURE OF KIDNEY 50205 RENAL BIOPSY; PERCUTANEOUS, BY SURGICAL EXPOSURE OF KIDNEY 01 00 40 2/1/1999 $114.50 50240 NEPHRECTOMY, PARTIAL 01 00 10 2/1/1999 $141.50 50240 NEPHRECTOMY, PARTIAL 01 00 20 2/1/1999 $706.50 50240 NEPHRECTOMY, PARTIAL 01 00 40 2/1/1999 $397.50 50340 RECIPIENT NEPHRECTOMY (SEPARATE PROCEDURE) 01 00 10 2/1/1999 $124.20 50340 RECIPIENT NEPHRECTOMY (SEPARATE PROCEDURE) 01 00 20 2/1/1999 $621.00 50340 RECIPIENT NEPHRECTOMY (SEPARATE PROCEDURE) 01 00 40 2/1/1999 $307.50 50360 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; EXCLUDING DONOR AND RECIPIENT NEPHRECTOMY 01 00 10 2/1/1999 $186.00 50360 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; EXCLUDING DONOR AND RECIPIENT NEPHRECTOMY 01 00 20 2/1/1999 $931.00 50360 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; EXCLUDING DONOR AND RECIPIENT NEPHRECTOMY 01 00 40 2/1/1999 $461.00 Page 9 of 34
50365 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; W/RECIPIENT NEPHRECTOMY 01 00 10 2/1/1999 $200.00 50365 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; W/RECIPIENT NEPHRECTOMY 01 00 20 2/1/1999 $1,000.00 50365 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; W/RECIPIENT NEPHRECTOMY 01 00 40 2/1/1999 $768.50 50370 REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT 01 00 10 2/1/1999 $155.50 50370 REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT 01 00 20 2/1/1999 $777.50 50370 REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT 01 00 40 2/1/1999 $382.00 71010 RADIOLOGIC EXAM, CHEST; SINGLE VIEW, FRONTAL 01 00 54 2/1/1999 $19.00 71010 RADIOLOGIC EXAM, CHEST; SINGLE VIEW, FRONTAL 21 04 54 1/1/1995 $19.00 71010 RADIOLOGIC EXAM, CHEST; SINGLE VIEW, FRONTAL 01 00 57 2/1/1999 $7.50 71010 RADIOLOGIC EXAM, CHEST; SINGLE VIEW, FRONTAL 21 04 57 1/1/1995 $7.50 71010 RADIOLOGIC EXAM, CHEST; SINGLE VIEW, FRONTAL 11 00 RD 1/1/1999 $11.50 71010 RADIOLOGIC EXAM, CHEST; SINGLE VIEW, FRONTAL 21 04 RD 1/1/1995 $11.50 Page 10 of 34
71015 RADIOLOGIC EXAM,CHEST;STEREO,FRONTAL 01 00 54 2/1/1999 $19.00 71015 RADIOLOGIC EXAM,CHEST;STEREO,FRONTAL 21 04 54 1/1/1995 $19.00 71015 RADIOLOGIC EXAM,CHEST;STEREO,FRONTAL 01 00 57 2/1/1999 $7.50 71015 RADIOLOGIC EXAM,CHEST;STEREO,FRONTAL 21 04 57 1/1/1995 $7.50 71015 RADIOLOGIC EXAM,CHEST;STEREO,FRONTAL 11 00 RD 1/1/1999 $11.50 71015 RADIOLOGIC EXAM,CHEST;STEREO,FRONTAL 21 04 RD 1/1/1995 $11.50 71020 RADIOLOGIC EXAM, CHEST; 2 VIEWS, FRONTAL & LATERAL 01 00 54 2/1/1999 $30.00 71020 RADIOLOGIC EXAM, CHEST; 2 VIEWS, FRONTAL & LATERAL 21 04 54 1/1/1995 $30.00 71020 RADIOLOGIC EXAM, CHEST; 2 VIEWS, FRONTAL & LATERAL 01 00 57 2/1/1999 $15.00 71020 RADIOLOGIC EXAM, CHEST; 2 VIEWS, FRONTAL & LATERAL 21 04 57 1/1/1995 $15.00 71020 RADIOLOGIC EXAM, CHEST; 2 VIEWS, FRONTAL & LATERAL 11 00 RD 1/1/1999 $15.00 71020 RADIOLOGIC EXAM, CHEST; 2 VIEWS, FRONTAL & LATERAL 21 04 RD 1/1/1995 $15.00 Page 11 of 34
71021 RADIOLOGIC EXAMINATION, CHEST; TWO VIEWS, FRONTAL AND LATERAL WITH APICAL LORDOTIC PROCEDURE 01 00 54 2/1/1999 $30.00 71021 RADIOLOGIC EXAMINATION, CHEST; TWO VIEWS, FRONTAL AND LATERAL WITH APICAL LORDOTIC PROCEDURE 01 00 57 2/1/1999 $15.00 71021 RADIOLOGIC EXAMINATION, CHEST; TWO VIEWS, FRONTAL AND LATERAL WITH APICAL LORDOTIC PROCEDURE 11 00 RD 1/1/1999 $15.00 71030 RADIOLOGIC EXAM, CHEST, COMPLETE, MIN 4VIEWS 01 00 54 2/1/1999 $37.50 71030 RADIOLOGIC EXAM, CHEST, COMPLETE, MIN 4VIEWS 01 00 57 2/1/1999 $15.00 71030 RADIOLOGIC EXAM, CHEST, COMPLETE, MIN 4VIEWS 11 00 RD 1/1/1999 $22.50 74475 INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 54 2/1/1999 $140.00 74475 INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 57 2/1/1999 $60.00 74475 INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION 11 00 RD 1/1/1999 $80.00 75658 ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 54 2/1/1999 $65.00 75658 ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 57 2/1/1999 $26.00 Page 12 of 34
75658 ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 11 00 RD 1/1/1999 $39.00 75790 ANGIOGRAPHY, ARTERIOVENOUS SHUNT (E.G. DIALYSIS PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 54 2/1/1999 $315.00 75790 ANGIOGRAPHY, ARTERIOVENOUS SHUNT (E.G. DIALYSIS PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 57 2/1/1999 $126.00 75790 ANGIOGRAPHY, ARTERIOVENOUS SHUNT (E.G. DIALYSIS PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION 11 00 RD 1/1/1999 $189.00 75809 SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING NONVASCULAR SHUNT (EG, LEVEEN SHUNT, VENTRICULOPERITONEAL SHUNT), RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 54 2/1/1999 $79.00 75809 SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING NONVASCULAR SHUNT (EG, LEVEEN SHUNT, VENTRICULOPERITONEAL SHUNT), RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 57 2/1/1999 $32.00 75809 SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING NONVASCULAR SHUNT (EG, LEVEEN SHUNT, VENTRICULOPERITONEAL SHUNT), RADIOLOGICAL SUPERVISION AND INTERPRETATION 11 00 RD 1/1/1999 $47.00 75820 VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 54 2/1/1999 $37.50 75820 VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 01 00 57 2/1/1999 $15.00 75820 VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 11 00 RD 1/1/1999 $22.50 Page 13 of 34
75962 TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY 01 00 54 2/1/1999 $496.00 75962 TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY 01 00 57 2/1/1999 $198.40 75962 TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY 11 00 RD 1/1/1999 $297.60 76705 ECHOGRAPHY, ABDOMINAL, B-SCAN &/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED ETC. (E.G. SINGLE ORGAN, QUADRANT, FOLLOW-UP) 01 00 54 2/1/1999 $62.50 76705 ECHOGRAPHY, ABDOMINAL, B-SCAN &/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED ETC. (E.G. SINGLE ORGAN, QUADRANT, FOLLOW-UP) 01 00 57 2/1/1999 $25.00 76705 ECHOGRAPHY, ABDOMINAL, B-SCAN &/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED ETC. (E.G. SINGLE ORGAN, QUADRANT, FOLLOW-UP) 11 00 RD 1/1/1999 $37.50 76778 ECHOGRAPHY OF TRANSPLANTED KIDNEY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION WITH OR WITHOUT DUPLEX DOPPLER STUDIES 01 00 54 2/1/1999 $81.50 76778 ECHOGRAPHY OF TRANSPLANTED KIDNEY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION WITH OR WITHOUT DUPLEX DOPPLER STUDIES 01 00 57 2/1/1999 $32.50 76778 ECHOGRAPHY OF TRANSPLANTED KIDNEY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION WITH OR WITHOUT DUPLEX DOPPLER STUDIES 11 00 RD 1/1/1999 $49.00 76936 ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDO-ANEURYSM OR ARTERIO-VENOUS FISTULAE(INCLUDES DIAGNOSTIC ULTRASOUND EVALUATION, COMPRESSION OF LESION & IMAGING) 01 00 54 2/1/1999 $263.62 Page 14 of 34
76936 ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDO-ANEURYSM OR ARTERIO-VENOUS FISTULAE(INCLUDES DIAGNOSTIC ULTRASOUND EVALUATION, COMPRESSION OF LESION & IMAGING) 01 00 57 2/1/1999 $69.17 76936 ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDO-ANEURYSM OR ARTERIO-VENOUS FISTULAE(INCLUDES DIAGNOSTIC ULTRASOUND EVALUATION, COMPRESSION OF LESION & IMAGING) 11 00 RD 1/1/1999 $194.46 78291 PERITONEAL-VENOUS SHUNT PATENCY TEST (E.G., FOR LAVEEN, DENVER SHUNT) 01 00 53 2/1/1999 $160.00 78291 PERITONEAL-VENOUS SHUNT PATENCY TEST (E.G., FOR LAVEEN, DENVER SHUNT) 01 00 58 2/1/1999 $50.00 78291 PERITONEAL-VENOUS SHUNT PATENCY TEST (E.G., FOR LAVEEN, DENVER SHUNT) 11 00 RN 1/1/1999 $110.00 78700 KIDNEY IMAGING; STATIC ONLY 01 00 53 2/1/1999 $69.00 78700 KIDNEY IMAGING; STATIC ONLY 01 00 58 2/1/1999 $27.50 78700 KIDNEY IMAGING; STATIC ONLY 11 00 RN 1/1/1999 $41.50 78701 KIDNEY IMAGING; WITH VASCULAR FLOW 01 00 53 2/1/1999 $92.50 78701 KIDNEY IMAGING; WITH VASCULAR FLOW 01 00 58 2/1/1999 $37.50 78701 KIDNEY IMAGING; WITH VASCULAR FLOW 11 00 RN 1/1/1999 $55.00 Page 15 of 34
78704 KIDNEY IMAGING; WITH FUNCTION STUDY (IE, IMAGING RENOGRAM) 01 00 53 2/1/1999 $109.00 78704 KIDNEY IMAGING; WITH FUNCTION STUDY (IE, IMAGING RENOGRAM) 01 00 58 2/1/1999 $44.00 78704 KIDNEY IMAGING; WITH FUNCTION STUDY (IE, IMAGING RENOGRAM) 11 00 RN 1/1/1999 $65.00 78707 KIDNEY IMAGING; WITH VASCULAR FLOW AND FUNCTION; SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION 01 00 53 2/1/1999 $114.00 78707 KIDNEY IMAGING; WITH VASCULAR FLOW AND FUNCTION; SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION 01 00 58 2/1/1999 $45.00 78707 KIDNEY IMAGING; WITH VASCULAR FLOW AND FUNCTION; SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION 11 00 RN 1/1/1999 $69.00 78710 KIDNEY IMAGING, TOMOGRAPHIC (SPECT) 01 00 53 2/1/1999 $233.45 78710 KIDNEY IMAGING, TOMOGRAPHIC (SPECT) 01 00 58 2/1/1999 $33.48 78710 KIDNEY IMAGING, TOMOGRAPHIC (SPECT) 11 00 RN 1/1/1999 $199.97 78715 KIDNEY VASCULAR FLOW ONLY 01 00 53 2/1/1999 $49.00 78715 KIDNEY VASCULAR FLOW ONLY 01 00 58 2/1/1999 $20.00 78715 KIDNEY VASCULAR FLOW ONLY 11 00 RN 1/1/1999 $29.00 Page 16 of 34
78725 KIDNEY FUNCTION STUDY WITHOUT PHARMACOLOGIC INTERVENTION 01 00 53 2/1/1999 $100.00 78725 KIDNEY FUNCTION STUDY WITHOUT PHARMACOLOGIC INTERVENTION 01 00 58 2/1/1999 $30.00 78725 KIDNEY FUNCTION STUDY WITHOUT PHARMACOLOGIC INTERVENTION 11 00 RN 1/1/1999 $70.00 80002 AUTOMATED TEST;1 OR 2 CLINICAL CHEMISTRY TEST(S) 21 04 86 1/1/1995 $7.00 80003 AUTOMATED TEST;3 CLINICAL CHEMISTRY TEST(TESTS) 21 04 86 1/1/1995 $7.00 80004 AUTOMATED TEST;4 CLINICAL CHEMISTRY TEST(TESTS) 21 04 86 1/1/1995 $7.00 80005 AUTOMATED TEST;5 CLINICAL CHEMISTRY TEST(TESTS) 21 04 86 1/1/1995 $8.00 80006 AUTOMATED TEST;6 CLINICAL CHEMISTRY TEST(TESTS) 21 04 86 1/1/1995 $8.00 80007 AUTOMATED TEST;7 CLINICAL CHEMISTRY TEST(TESTS) 21 04 86 1/1/1995 $8.00 80008 AUTOMATED TEST;8 CLINICAL CHEMISTRY TEST(TESTS) 21 04 86 1/1/1995 $8.00 80009 AUTOMATED TEST;9 CLINICAL CHEMISTRY TEST(TESTS) 21 04 86 1/1/1995 $8.00 80010 AUTOMATED TEST;10 CLINICAL CHEMISTRY TESTS 21 04 86 1/1/1995 $8.00 Page 17 of 34
80011 AUTOMATED TEST;11 CLINICAL CHEMISTRY TESTS 21 04 86 1/1/1995 $8.00 80012 AUTOMATED TEST;12 CLINICAL CHEMISTRY TESTS 21 04 86 1/1/1995 $8.00 80016 AUTOMATED TEST;13-16 CLINICAL CHEMISTRY TESTS 21 04 86 1/1/1995 $11.00 80018 AUTOMATED MULTICHANNEL TEST;17-18 CLINICAL CHEMISTRY TESTS 21 04 86 1/1/1995 $12.00 80019 AUTOMATED TEST;19 OR MORE CLINICAL CHEMISTRY TESTS 21 04 86 1/1/1995 $12.50 80049 BASIC METABOLIC PANEL WHICH INCLUDES CARBON DIOXIDE (82374); CHLORIDE (82435); CREATININE (82565); GLUCOSE (82947); POTASSIUM (84132); SODIUM (84295); UREA NITROGEN (BUN) (84520). 11 00 86 1/1/1999 $8.00 80050 COMP METABOLIC PANEL (80054); HEMOGRAM, AUTOMATED, AND MANUAL DIFFERENTIAL WBC COUNT(CBC)(85022) OR HEMOGRAM AND PLATELET COUNT, AUTOMATED, AND AUTOMATED COMPLETE DIFFERENTIAL WBC COUNT(CBC)(85025); THYROID STIMULATING HORMONE(TSH)(84443) 11 00 86 1/1/1999 $8.00 80051 ELECTROLYTE PANEL WHICH INCLUDES CARBON DIOXIDE (82374); CHLORIDE (82435); POTASSIUM (84132); SODIUM (84295) 11 00 86 1/1/1999 $7.00 80054 COMP METABOLIC PANEL WHICH INCL ALBU(82040); BILIRU, TOTAL OR DIRECT(82250); CALC(82310); CHLOR(82435); CREAT(82565); GLUC(82947); PHOS, ALKALINE(84075); POTASS(84132); PROT, TOTAL(84155); SODIUM (84295); TRANSFERASE, ASPARTATE AMINO(AST)(SGOT)(84450); UREA NITRO (BUN)(84520) 11 00 86 1/1/1999 $8.00 Page 18 of 34
80091 THYROID PANEL;THYROXINE,TOTAL AND TRIODOTHYROINE (T-3),RESIN UPTAKE 11 00 86 1/1/1999 $19.86 4 PER MONTH 80091 THYROID PANEL;THYROXINE,TOTAL AND TRIODOTHYROINE (T-3),RESIN UPTAKE 21 04 86 1/1/1995 $11.40 4 PER MONTH 80092 THYROID PANEL;W/THYROID STIMULAT HORMONE 11 00 86 1/1/1999 $41.67 4 PER MONTH 80092 THYROID PANEL;W/THYROID STIMULAT HORMONE 21 04 86 1/1/1995 $63.00 4 PER MONTH 82040 ALBUMIN; SERUM 11 00 86 1/1/1999 $3.65 82250 BILIRUBIN; TOTAL OR DIRECT 11 00 86 1/1/1999 $6.93 82251 BILIRUBIN; TOTAL AND DIRECT 11 00 86 1/1/1999 $7.19 82310 CALCIUM: TOTAL 11 00 86 1/1/1999 $7.11 82374 CARBON DIOXIDE (BICARBONATE) 11 00 86 1/1/1999 $6.72 82435 CHLORIDE; BLOOD 11 00 86 1/1/1999 $6.34 82565 CREATININE;BLOOD 11 00 86 1/1/1999 $7.06 4 PER MONTH 82565 CREATININE;BLOOD 21 04 86 1/1/1995 $3.00 4 PER MONTH Page 19 of 34
82570 CREATININE;OTHER SOURCE 21 04 86 1/1/1995 $6.00 82575 CREATININE;CLEARANCE 11 00 86 1/1/1999 $10.00 4 PER MONTH 82746 FOLIC ACID; SERUM 11 00 86 1/1/1999 $12.00 82947 GLUCOSE; QUANTITATIVE 11 00 86 1/1/1999 $4.00 83550 IRON BINDING CAPACITY 11 00 86 1/1/1999 $5.00 83690 LIPASE 11 00 86 1/1/1999 $5.00 83718 LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTROL (HDL CHOLESTEROL) 11 00 86 1/1/1999 $7.00 83719 LIPOPROTEIN, DIRECT MEASUREMENT VLDL CHOLESTEROL 11 00 86 1/1/1999 $12.00 83721 LIPOPROTEIN, DIRECT MEASUREMENT, LDL CHOLESTEROL 11 00 86 1/1/1999 $12.00 84075 PHOSPHATASE, ALKALINE 11 00 86 1/1/1999 $7.14 84132 POTASSIUM; SERUM 11 00 86 1/1/1999 $6.34 84155 PROTEIN; TOTAL, EXCEPT REFRACTOMETRY 11 00 86 1/1/1999 $5.05 Page 20 of 34
84295 SODIUM; SERUM 11 00 86 1/1/1999 $6.60 84443 THYROID STIMULATING HORMONE (TSH) 11 00 86 1/1/1999 $23.22 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 11 00 86 1/1/1999 $7.13 84520 UREA NITROGEN; QUANTITATIVE 11 00 86 1/1/1999 $5.44 85013 BLOOD COUNT;SPUN MICROHEMATOCRIT 11 00 86 1/1/1999 $3.27 85014 BLOOD COUNT; OTHER THAN SPUN HEMATOCRIT 11 00 86 1/1/1999 $3.27 85018 BLOOD COUNT; HEMOGLOBIN 11 00 86 1/1/1999 $3.27 85022 HEMOGRAM, AUTOMATED AND MANUAL DIFFERENTIAL WBC COUNT (CBC) 11 00 86 1/1/1999 $6.00 85025 HEMOGRAM AND PLATELET COUNT, AUTOMATED, AND AUTOMATED COMPLETE DIFFERENTIAL WBC COUNT (CBC) 11 00 86 1/1/1999 $6.00 90918 END STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL MONTH; FOR PATIENTS UNDER 2 YRS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACYOF NUTRITION, ASSESSMENT OF GROWTH & DEVELOPMENT, & COUNSELING OF PARENTS 01 00 60 2/1/1999 $225.00 1 PER MONTH Page 21 of 34
90919 ESRD RELATED SERVICES PER FULL MONTH; FOR PATIENTS BETWEEN 2 & 11 YRS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH & DEVELOPMENT, & COUNSELING OF PARENTS 01 00 60 2/1/1999 $225.00 1 PER MONTH 90920 ESRD RELATED SERVICES PER FULL MONTH; FOR PATIENTS BETWEEN 12 & 19 YRS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH & DEVELOPMENT, & COUNSELING OF PARENTS 01 00 60 2/1/1999 $225.00 1 PER MONTH 90921 ESRD RELATED SERVICES PER FULL MONTH; FOR PATIENTS 20 YRS OF AGE & OVER. 01 00 60 2/1/1999 $225.00 1 PER MONTH 90922 ESRD RELATED SERVICES (LESS THAN FULL MONTH), PER DAY; FOR PATIENTS UNDER 2 YRS OF AGE. 01 00 60 2/1/1999 $16.00 90923 ESRD RELATED SERVICES (LESS THAN FULL MONTH), PER DAY; FOR PATIENTS BETWEEN 2 & 11 YRS OF AGE. 01 00 60 2/1/1999 $16.00 90924 ESRD RELATED SERVICES (LESS THAN FULL MONTH), PER DAY; FOR PATIENTS BETWEEN 12 & 19 YRS OF AGE. 01 00 60 2/1/1999 $16.00 90925 ESRD RELATED SERVICES (LESS THAN FULL MONTH), PER DAY; FOR PATIENTS 20 YRS OF AGE AND OVER. 01 00 60 2/1/1999 $16.00 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN EVALUATION 01 00 60 2/1/1999 $40.00 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN EVALUATION 11 00 AP 1/1/1999 $115.00 16 PER MONTH 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN EVALUATION 21 04 AP 1/1/1995 $115.00 16 PER MONTH Page 22 of 34
90937 HEMODIALYSIS PROCEDURE REQUIRING REPEATED EVALUATION(S) WITH OR WITHOUT SUBSTANTIAL REVISION OF DIALYSIS PRESCRIPTION 01 00 60 2/1/1999 $52.50 16 PER MONTH 90937 HEMODIALYSIS PROCEDURE REQUIRING REPEATED EVALUATION(S) WITH OR WITHOUT SUBSTANTIAL REVISION OF DIALYSIS PRESCRIPTION 11 00 AP 1/1/1999 $115.00 16 PER MONTH 90937 HEMODIALYSIS PROCEDURE REQUIRING REPEATED EVALUATION(S) WITH OR WITHOUT SUBSTANTIAL REVISION OF DIALYSIS PRESCRIPTION 21 04 AP 1/1/1995 $115.00 16 PER MONTH 90945 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL,HEMOFILTRATION), WITH SINGLE PHYSICIAN EVALUATION 01 00 60 2/1/1999 $40.00 1 PER DAY 90945 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL,HEMOFILTRATION), WITH SINGLE PHYSICIAN EVALUATION 11 00 AP 1/1/1999 $35.00 1 PER DAY 90945 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL,HEMOFILTRATION), WITH SINGLE PHYSICIAN EVALUATION 21 04 AP 1/1/1995 $35.00 1 PER DAY 90947 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL, HEMOFILTRATION) REQUIRING REPEATED EVALUATIONS, WITH OR WITHOUT SUBSTANTIAL REVISION OF DIALYSIS PRESCRIPTION 01 00 60 2/1/1999 $52.50 1 PER DAY 90947 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL, HEMOFILTRATION) REQUIRING REPEATED EVALUATIONS, WITH OR WITHOUT SUBSTANTIAL REVISION OF DIALYSIS PRESCRIPTION 11 00 AP 1/1/1999 $35.00 1 PER DAY 90947 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL, HEMOFILTRATION) REQUIRING REPEATED EVALUATIONS, WITH OR WITHOUT SUBSTANTIAL REVISION OF DIALYSIS PRESCRIPTION 21 04 AP 1/1/1995 $35.00 1 PER DAY Page 23 of 34
90989 DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHERE APPLICABLE, ANY MODE, COMPLETED COURSE 01 00 60 2/1/1999 $500.00 24 PER PATIENT 90989 DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHERE APPLICABLE, ANY MODE, COMPLETED COURSE 11 00 AP 1/1/1999 $165.00 24 PER PATIENT 90989 DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHERE APPLICABLE, ANY MODE, COMPLETED COURSE 21 04 AP 1/1/1995 $165.00 24 PER PATIENT 90993 DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHERE APPLICABLE, ANY MODE, COURSE NOT COMPLETED, PER TRAINING SESSION 01 00 60 2/1/1999 $50.00 90993 DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHERE APPLICABLE, ANY MODE, COURSE NOT COMPLETED, PER TRAINING SESSION 21 04 AP 1/1/1995 $165.00 90997 HEMOPERFUSION (E.G., WITH ACTIVATED CHARCOAL OR RESIN) 11 00 AP 1/1/1999 $480.00 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT 01 00 80 2/1/1999 $21.50 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT 11 00 80 1/1/1999 $21.50 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT 21 04 80 1/1/1995 $21.50 93005 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, W/O INTERPRETATION AND REPORT 01 00 AZ 2/1/1999 $11.50 93005 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, W/O INTERPRETATION AND REPORT 11 00 AZ 1/1/1999 $11.50 Page 24 of 34
93005 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, W/O INTERPRETATION AND REPORT 21 04 AZ 1/1/1995 $11.50 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY 01 00 AY 2/1/1999 $7.50 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY 11 00 AY 1/1/1999 $7.50 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY 21 04 AY 1/1/1995 $7.50 93990 DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, BODY OF ACCESS AND VENOUS OUTFLOW) 01 00 80 2/1/1999 $94.98 93990 DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, BODY OF ACCESS AND VENOUS OUTFLOW) 11 00 80 1/1/1999 $94.98 93990 DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, BODY OF ACCESS AND VENOUS OUTFLOW) 01 00 AY 2/1/1999 $14.47 93990 DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, BODY OF ACCESS AND VENOUS OUTFLOW) 11 00 AZ 1/1/1999 $80.51 99201 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING 01 00 60 2/1/1999 $20.00 99202 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING 01 00 60 2/1/1999 $20.00 Page 25 of 34
99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY 01 00 60 2/1/1999 $20.00 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY 01 00 60 2/1/1999 $20.00 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY 01 00 60 2/1/1999 $30.00 99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES 01 00 60 2/1/1999 $20.00 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE THREE KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING 01 00 60 2/1/1999 $20.00 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE THREE KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY 01 00 60 2/1/1999 $20.00 Page 26 of 34
99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE THREE KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY 01 00 60 2/1/1999 $20.00 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY 01 00 60 2/1/1999 $20.00 99221 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE THREE KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY 01 00 60 2/1/1999 $29.50 99222 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY 01 00 60 2/1/1999 $29.50 99223 INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY 01 00 60 2/1/1999 $42.00 99231 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE THREE KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY 01 00 60 2/1/1999 $17.00 Page 27 of 34
99232 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE THREE KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY: AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY 01 00 60 2/1/1999 $17.00 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST TWO OF THESE THREE KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY 01 00 60 2/1/1999 $17.00 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES OR LESS 01 00 60 2/1/1999 $17.00 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE THAN 30 MINUTES 01 00 60 2/1/1999 $17.00 99241 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING 01 00 90 2/1/1999 $30.00 99242 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIES THESE THREE KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING 01 00 90 2/1/1999 $30.00 99243 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY 01 00 90 2/1/1999 $30.00 Page 28 of 34
99244 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY 01 00 90 2/1/1999 $49.00 99245 OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY 01 00 90 2/1/1999 $49.00 99251 INITIAL INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING 01 00 90 2/1/1999 $30.00 99252 INITIAL INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING 01 00 90 2/1/1999 $30.00 99253 INITIAL INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY 01 00 90 2/1/1999 $30.00 99254 INITIAL INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY 01 00 90 2/1/1999 $49.00 99255 INITIAL INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY 01 00 90 2/1/1999 $49.00 Page 29 of 34
E1520 HEPARIN INFUSION PUMP FOR DIALYSIS 11 00 AP 1/1/1999 $67.50 E1590 HEMODIALYSIS MACHINE 11 00 AP 1/1/1999 $300.00 E1610 REVERSE OSMOSIS WATER PURIFICATION SYSTEM 11 00 AP 1/1/1999 $113.85 E1630 RECIPROCATING PERITONEAL DIALYSIS SYSTEM 11 00 AP 1/1/1999 $123.00 J0635 INJECTION, CALCITRIOL, 1 MCG AMP. 11 00 AE 1/1/1999 $12.56 J0635 INJECTION, CALCITRIOL, 1 MCG AMP. 21 04 AE 9/1/1998 $12.10 J0690 CEFAZOLIN SODIUM, UP TO 500 MG 11 00 AE 2/1/2001 $2.06 J0690 CEFAZOLIN SODIUM, UP TO 500 MG 21 04 AE 2/1/2001 $2.06 J0713 INJECTION, CEFTAZIDIME, PER 500 MG 11 00 AE 1/1/1999 $6.75 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG 11 00 AE 1/1/1999 $2.19 J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG 21 04 AE 9/1/1998 $2.19 J1750 INJECTION, INFED, 50 MG 11 00 AE 7/1/2000 $17.90 Page 30 of 34
J1750 INJECTION, INFED, 50 MG 21 04 AE 7/1/2000 $17.90 J1760 INJECTION, IRON DEXTRAN, 2 CC 11 00 AE 1/1/1999 $35.81 J1760 INJECTION, IRON DEXTRAN, 2 CC 21 04 AE 9/1/1998 $35.82 J1770 INJECTION, IRON DEXTRAN, 5 CC 11 00 AE 1/1/1999 $89.53 J1770 INJECTION, IRON DEXTRAN, 5 CC 21 04 AE 9/1/1998 $89.54 J1780 INJECTION, IRON DEXTRAN, 10 CC 11 00 AE 1/1/1999 $179.07 J1780 INJECTION, IRON DEXTRAN, 10 CC 21 04 AE 9/1/1998 $179.08 J3260 TOBRAMYCIN SULFATE, UP TO 80 MG 11 00 AE 2/1/2001 $12.31 J3260 TOBRAMYCIN SULFATE, UP TO 80 MG 21 04 AE 2/1/2001 $12.31 J3364 INJECTION, UROKINASE, 5000 IU VIAL 11 00 AE 1/1/1999 $52.83 J3364 INJECTION, UROKINASE, 5000 IU VIAL 21 04 AE 9/1/1998 $51.25 J3365 INJECTION, IV, UROKINASE, 250,000 I.U. VIAL 11 00 AE 1/1/1999 $444.39 Page 31 of 34
J3365 INJECTION, IV, UROKINASE, 250,000 I.U. VIAL 21 04 AE 9/1/1998 $411.64 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG 11 00 AE 1/1/1999 $7.41 J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG 21 04 AE 9/1/1998 $9.25 J7513 INJECTION, DACLIZUMAB, 5 MG/ML 11 00 AE 1/1/1999 $79.46 J9696 CEFTRIAXONE SODIUM, PER 250 MG 11 00 AE 2/1/2001 $13.35 J9696 CEFTRIAXONE SODIUM, PER 250 MG 21 04 AE 2/1/2001 $13.35 P9010 BLOOD (WHOLE) FOR TRANSFUSION, PER UNIT 11 00 9B 1/1/1999 $30.00 3 PINTS/CALENDAR YEAR & INCLUDES BLOOD PRODUCT, SUPPLIES, & BLOOD PROCESSING FEES P9010 BLOOD (WHOLE) FOR TRANSFUSION, PER UNIT 21 04 9B 1/1/1995 $40.00 3 PINTS/CALENDAR YEAR & INCLUDES BLOOD PRODUCT, SUPPLIES, & BLOOD PROCESSING FEES P9021 RED BLOOD CELLS, EACH UNIT 11 00 9B 1/1/1999 $30.00 3 PINTS/CALENDAR YEAR & INCLUDES BLOOD PRODUCT, SUPPLIES, & BLOOD PROCESSING FEES W0918 TRAINING FOR HOME DIALYSIS, COMPREHENSIVE SERVICE, PER DIALYSIS 11 00 AP 1/1/1999 $165.00 24 PER PATIENT W0919 BACK-UP DIALYSIS TREATMENT 11 00 AP 1/1/1999 $165.00 Page 32 of 34
W0920 INCENTER TREATMENT, PER DIALYSIS 11 00 AP 1/1/1999 $115.00 W0921 HOME TREATMENT FOR CAPD PER DAY 11 00 AP 1/1/1999 $35.00 W0922 HOME TREATMENT FOR CCPD PER DAY 11 00 AP 1/1/1999 $35.00 W0923 HOME TREATMENT HEMODIALYSIS, IPD PER DIALYSIS 11 00 AP 1/1/1999 $35.00 W0924 KIDNEY MACHINE, INSTALLATION FEE 11 00 AP 1/1/1999 $175.00 1 PER PATIENT W0924 KIDNEY MACHINE, INSTALLATION FEE 21 04 AP 1/1/1995 $175.00 1 PER PATIENT W0925 KIDNEY MACHINE, MONTHLY RENTAL 11 00 AP 1/1/1999 $163.00 FEE PER MONTH W0925 KIDNEY MACHINE, MONTHLY RENTAL 21 04 AP 1/1/1995 $163.00 FEE PER MONTH W0926 WATER SOFTENER, INSTALLATION FEE, IN CONJUNCTION WITH REVERSE OSMOSIS SYSTEM ONLY 11 00 AP 1/1/1999 $50.00 1 PER PATIENT W0926 WATER SOFTENER, INSTALLATION FEE, IN CONJUNCTION WITH REVERSE OSMOSIS SYSTEM ONLY 21 04 AP 1/1/1995 $50.00 1 PER PATIENT W0927 WATER SOFTENER, MONTHLY RENTAL, IN CONJUNCTION WITH REVERSE OSMOSIS SYSTEM ONLY 11 00 AP 1/1/1999 $6.00 FEE PER MONTH W0927 WATER SOFTENER, MONTHLY RENTAL, IN CONJUNCTION WITH REVERSE OSMOSIS SYSTEM ONLY 21 04 AP 1/1/1995 $6.00 FEE PER MONTH Page 33 of 34
W0928 ANCILLARY DIALYSIS, NON-EXPENDABLE HOME EQUIPMENT (ONE TIME CHARGE) 11 00 AP 1/1/1999 $200.00 1 PER PATIENT W0928 ANCILLARY DIALYSIS, NON-EXPENDABLE HOME EQUIPMENT (ONE TIME CHARGE) 21 04 AP 1/1/1995 $200.00 1 PER PATIENT Page 34 of 34